Postpartum Hemorrhage Dr. Yasir Katib MB BS, FRCSC

Postpartum Haemorrhage Introduction Risk Factors Prevention Treatment Pelvic Haematoma Umbrella Pack Uterine Inversion

PPH - Introduction Acute blood loss – most common cause of hypotension in obstetrics Usually occurs immediately before or after placental delivery Most commonly results when uterus fails to contract - effective haemostasis dependent on contraction of myometrium (compresses severed vessels)

PPH - Introduction Factors Predisposing to Myometrial Dysfunction Uterine Overdistention Multiple Pregnancy Fetal Macrosomia Hydramnios Oxytocin-stimulated Labour Uterine Relaxants Amnionitis

PPH - Introduction Abnormal placentation Placenta accreta – attaches directly into myometrium Placenta increta - extends deep into myometrium Placenta percreta - through the uterine serosa & even into the surrounding organs PPH occurs b/c myometrial tissue present at implantation site insufficient to constrict spiral arteries of the uterus. Attempting to remove the abnormal placenta frequently results in uncontrolled haemorrhage because of large open sinuses in the myometrium.

PPH – Risk Factors (Obstetric Haemorrhage >1 L) Placental abruption Placenta previa Multiple pregnancy Obesity Retained placenta Induced labour Episiotomy Birth weight > 4 kg

PPH – Prevention Active management of 3rd stage of labour & spontaneous delivery of placenta @ time of C/S Umbilical cord clamping within 30s of delivery, gentle cord traction, followed by IM or IV oxytocin before delivery of placenta Oxytocin s length of 3rd stage of labour (~ 5 min) & low incidence of manual removal (2%) In absence of sig. maternal haemorrhage, additional 30 min of expectant management allow ½ of retained placentas to deliver spontaneously Spont. Delivery of placenta s risk of endometritis 7x, s blood loss by 30% (RCT)

PPH – Tx (Manual) Manual digital exploration of uterus to r/o possibility of retained placental fragments

PPH – Tx (Manual) If not detected, manual massage of uterus should be started

PPH – Tx (Pharmacologic) At the same time, initial Tx of oxytocin 10-20 U/1000 mL of NS at rates as high as 500 mL in 10 min. If oxytocin fails, synthetic prostaglandin (Prostin, Upjohn) is 2nd line (0.25 mg IM in deltoid q1-2h X 5 doses) Ergovine (0.2 mg IM) used to be 2nd line Misoprostol (1000 g PR) in patients with refractory uterine bleeding shown (O’Brien et al.)

PPH – Tx (Surgical) Inspection for laceration of maternal tissues could be a likely cause of continued vaginal or cervical bleeding Repair

PPH – Tx (Surgical) 1st degree – involves fourchet, perineal skin & vaginal mucosal membrane 2nd degree – also involves muscles of perineal body; rectal sphincter remains intact

PPH – Tx (Surgical) 3rd degree – extends not only through the skin, mucous membrane & perineal body, but includes the anal sphincter

PPH – Tx (Surgical) 4th degree laceration – extends through the rectal mucosa

PPH – Tx (Surgical) Cervical laceration – NB to secure base of laceration (often a major source of bleeding); but difficult to suture

PPH – Tx (Surgical) If uterine bleeding not responsive to pharmacologic methods & no vaginal or cervical lacerations present, surgical exploration may be necessary Laceration of uterine vessels may be found (i.e. longitudinal lacerations of inner myometrium – thought to be an incomplete form of uterine rupture)

PPH – Tx (Surgical) If haemorrhage secondary to atony, vascular ligation often necessary Hypogastric artery ligation fallen out of favour b/c of prolonged OR time, technical difficulties & inconsistent clinical response If bilateral uterovarian vessel ligation does not stop bleeding, temporary occlusion of infundibulopelvic ligament (digital pressure or clamps) should be attempted – ligation indicated if this controls bleeding

PPH – Tx (Surgical) Instead, stepwise progression of uterine vessel ligation should be performed 1st – ligation of ascending branch of uterine arteries (in ~10-15% of atony, unilateral ligation of uterine artery sufficient to control bleeding; bilat will control an additional 75%) If bleeding persists, should attempt to interrupt blood flow between uterus & infundibulopelvic ligament via ligation of anastomosis of ovarian & uterine artery

PPH – Tx (Surgical)

PPH – Tx (Radiological) Advantages – d anaesthetic & surgical risks - identification & selective occlusion of specific vessels - avoid hysterectomy Could also use transient transcatheter uterine artery balloon for management of extreme haemorrhage

PPH – Tx (Radiological) Successfully used in postpartum bleeding from atony, bleeding from pelvic vessel laceration, post c-section haemorrhage & bleeding associated with extrauterine pregnancy Complications - postprocedure fever & pelvic infection (most common) - reflux of embolic material in nontargeted pelvic structures

PPH – Pelvic Hematoma Blood loss not always visible Occasionally, traumatic laceration of blood vessels can lead to pelvic haematoma formation 3 types Vulvar Vaginal Retroperitoneal

PPH – Pelvic Hematoma Vulvar D/t laceration of vessels in superficial fascia of either the ant. or post. pelvic triangle Usual signs : subacute volume loss & vulvar pain Blood loss limited by Colle’s fascia & urogenital diaphragm & anal fascia B/c of fascial boundaries, mass extends to skin & visible haematoma results Tx – volume support & surgical evacuation of blood & clots, pressure bandage, Foley catheter

PPH – Pelvic Hematoma

PPH – Pelvic Hematoma Vaginal Frequently associated with forceps delivery; may be spontaneous Less common than vulvar Blood accumulates in plane above level of pelvic diaphragm Unusual for large amounts of blood to collect Frequent complaint – severe rectal pressure Exam – large mass protruding into vagina Tx – incision of vagina & evacuation (even if delayed Dx)

PPH – Pelvic Hematoma

PPH – Pelvic Hematoma Retroperitoneal Least common Most dangerous to mother May not be impressive until sudden onset of hypotension/shock D/t laceration of one of vessels originating from hypogastric artery Tx : surgical exploration & ligation of hypogastric vessels unilaterally or bilaterally if needed

PPH – Uterine Inversion Characterized by partial delivery of the placenta, followed by rapid onset of shock ( usually before sig. blood loss) in the mother in the 3rd stage of labour Can be mistaken for partially separated placenta or aborted myoma Uncommon but life-threatening event Incidence : 1/2000 deliveries

PPH – Uterine Inversion Incomplete – if corpus does not pass through cervix Complete – if corpus passes through the cervix Prolapsed – if corpus extends through vaginal introitus Usually occurs in association with a fundally inserted placenta

PPH – Uterine Inversion Tx : fluid therapy & restoration of uterus to N position immediately upon recognition of inversion, without removing the placenta If initial efforts fail, use of either -mimetic agents or magnesium sulfate should be tried (esp. if severe maternal hypotension) Occasionally, impossible to reposition uterus vaginally & laparotomy necessary Once inversion corrected, oxytocic or prostaglandin agents should be given

The End